Our practice is dedicated, and we are required by applicable federal and state laws to maintain the privacy of your health information. These laws also require us to provide you with this Notice of our privacy practices and inform you of your right and our obligation concerning your health information. We are required to follow the privacy practices described below while this Notice is in effect. This Notice is effective as of April 14th, 2009, and will remain in effect until we replace it.

CHANGES TO NOTICE: We reserve the right to change this Notice and the privacy practices. We will alter this Notice to reflect changes and make the revised Notice available to you on request. Any changes we make to our privacy practices and/or this Notice may be applicable to health information created or received by us prior to the date of changes. You may request a copy of our Notice at any time. For more information about our privacy practices or for additional copies of this Notice, please contact us using the information listed at the end of the Notice.

PERMITTED USES AND DISCLOSURES OF HEALTH INFORMATION:

A. CONSENT: You should be aware that during our relationship with you, we will likely use and disclose health information about you for treatment, payment, and healthcare operation. Examples of these activities are as follows:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing the treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operation: We may use and disclose your health information in connection with our healthcare operation. Healthcare operation includes quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluation practitioner and provider performance, and other business operations.

Our chiropractic practices will seek to obtain consent from you, permitting us to use or disclose your health information for these activities. You should be aware that our chiropractic practice does not require obtaining or confirming the existence of consent prior to:

a) Emergency treatment

b) Treatment, when such treatment is required by law; or

c) Treatment of patients when communication barriers prevent obtaining consent.

You should also be aware that you have the right to revoke that consent at any time by providing the practice with any notice.

B. AUTHORIZATION: you may expressly authorize us to use your healthcare information for any purpose or disclose your health information to anyone by submitting such an authorization in writing. Upon receiving an authorization from you in writing, we may use or disclose your health information in accordance with that authorization. You may revoke an authorization at any time by notifying us in writing. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect unless you give us a written authorization. We can not use or disclose your health information for any reason except those permitted by this Notice.

C. DISCLOSURES TO FAMILY AND PERSONAL REPRESENTATIVES: We must disclose your health information to you, as described in the Patient Rights section of this Notice. Such disclosures will be made to any of your personal representatives appropriately authorized to have access and control of your health information. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare only if authorized to do so. In the event of your incapacity in emergency circumstances, we will disclose health information based on a determination using our professional judgement disclosing only health information that is directly relevant to the person’s involvement in your healthcare.

D. MARKETING: we will not use your health information for marketing communication without your written authorization.

E. USES OR DISCLOSURES REQUIRED BY LAW: We may use or disclose your health information when we are required to do so by law, including for public health reasons (e.g., disease reporting). In some instances, and in accordance with applicable law, we may be required to disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence, or the possible victim of other crimes.

F. PATIENT AND THIRD-PARTY PROTECTION: Only as permitted by law, we may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

G. LAW ENFORCEMENT/NATIONAL SECURITY: Under certain circumstances, we may disclose health information relating to members of the Armed Forces to military authorities. Under certain circumstances, we may also disclose health information relating to inmates or patients to correctional institutions or law enforcement personnel having lawful custody of those individuals. We may disclose health information in response to judicial proceedings and law enforcement inquiries as permitted by law and to authorized federal officials, health information required for lawful intelligence, counterintelligence, and other national security activities.

H. APPOINTMENT REMINDERS: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

PATIENT RIGHTS

A. ACCESS TO RECORDS: Upon submission of written request request you have the right to review or receive copies of your health information, with limited exceptions. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may request that we provide copies in a format other than photocopies, and we will use the format you request if it is readily available. We will charge you a reasonable cost-based fee relating to the production of such copies. If you request copies, we will charge you a reasonable fee for the labor of copying your records (not including record handling and record retrieval), a $1.00 per page for pages 11-60, $.50 per page for pages 61-400, and $.25 per page for pages over 400, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a reasonable cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of the Notice if you are instead in receiving a summary of your information instead of copies.

B. ACCOUNTING OF CERTAIN DISCLOSURES: Upon written request, you have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operation, and other activities authorized by you, for the last 6 years, but not before November 1st, 2011. If you request this account more than once in 12 months, we may charge you a reasonable cost-based fee for responding to these additional requests.

C. RESTRICTIONS AND ALTERNATIVE COMMUNICATIONS: You have the right to request that we place additional restrictions on our use or disclosure of your health information for treatment, payment, and healthcare operations purposes. Depending on the circumstances of your request, we may or may not agree to those restrictions. If we agree to your requested restrictions, we must abide by those restrictions, except in emergency treatment scenarios. You have the right to request that we communicate with you about your health information by alternative means or to alternative locations (e.g., at your place of business rather than your home). Such requests must be made in writing, must specify the alternative means or locations, and must provide a satisfactory explanation of how payments will be handled under the alternative means or location you request.

D. AMENDMENTS TO RECORDS: You have the right to request that we amend your health information. Such requests must be made in writing and must explain why the information should be amended. We may deny your request under certain circumstances.

E. ELECTRONIC NOTICES: If you receive this Notice on our Website or by electronic mail (e-mail), you are entitled to receive this notice in written form.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated our privacy rights, or you disagree with a decision we made or any decision we may make regarding the use, disclosure, or access to your health information, you may complain to us using the contact information listed below. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file such a complaint upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Please direct any of your questions or complaints to:

Dr. Andrea Ellis, DC

Phone: 214-987-9973

13140 Coit Rd. Suite 104 | Dallas, TX 75240